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22 Cards in this Set

  • Front
  • Back
Types of Nursing Interventions
-Interventions initiated by and dependent on a doctor's order
-Nurses are accountable for the dependent nursing interventions they implement
-If there are questions concerning the order - nurses are responsible for clarifying order before they implement it
-those interventions that can be initiated by the nurse without seeking the approval of another health professional - nurses are legally accountable for the interventions they implement
-those interventions that are jointly performed by the nurse and other health team members - they are collaborative actions
Goals of Implementation
Primary Prevention
-those activities directed toward promoting health and early detection of disease
Secondary Prevention
-those activities directed toward early diagnosis and prompt intervention
Tertiary Prevention
-those activities directed toward prevention of further disability, rehabilitation, and health maintenance (highest level of functioning)
Activities Involved
Legal Considerations
-Physician orders
Review of client data
Role/Client/Student Health Team Member
Delivery of Care
-Scientific Principles
-Nursing Principles
-Teaching Principles
Guidelines for Selecting and Stating Nursing Interventions
Nursing actions are the nurse's behaviors individually designed to meet the specific goals and objectives for a particular client
Nursing actions may be categorized as
-observations, planned and incidental
-administration of direct physical care
-patient education/health teaching
-execution of prescribed medical treatments
-therapeutic communication/counseling
-maintenance of a therapeutic environment
-conferring, coordination, and referrals
-patient advocacy
Components of the written nursing action/order
-Behavior of reader/nurse
-Recipient of action
-Frequency and specific time
Components of the written nursing action/order
-Should be listed in appropriate sequential order based on priority
-Correlated and specific to the outcomes/objectives that the client is to achieve
-Based on scientific rationale
-Specify who does what, where, when, how, and how often
Areas to evaluated include:
-Client response to nursing interventions - document objectively and in meaningful detail
-Achievement of expected outcomes (as stated in planning stage - met, partially met, or unmet)
-Revision of expected outcome of nursing treatment - Revision indicators include
-Ineffective nursing treatment (It's not working)
-Unacceptable nursing treatment (to client)
-Lack of achievement of outcome (? Behavior) (? Criteria)
Quality of care and continuity
Purpose of Documentation
-Provide quality and continuity of care
-Enhance communication among health team members
-Update the NCP as the client's condition changes by adding new data, change nursing diagnosis priorities, expected outcomes, and nursing care
Purpose of Documentation
-Assist in the nursing audit - review of records to insure quality client care
-Assist in research
-Education nurses, physicians, and other health team members
-Provide a legal record
Types of Medical Records
-each discipline's information is placed in the assigned area and at times
-advantages (easy to know where to chart)
records are fragmented
entries of each discipline is isolated
increases the difficulty in following the client problem, treatment, and evaluation of outcomes of treatment
Problem-Oriented Medical Record
-All the health team member's charting is integrated
-Major parts
Problem List (Nursing Diagnosis)
Progress Notes
oriented to the client problem, not the convenience of the health team members
client problems are easily identified
treatment plans and client response easily followed
time consuming
Types of Documentation
Flow Sheet
Clinical nursing notes
information written in chronological order
frequency of documentation depends on the client condition
words client or nurse usually not used
very useful in emergency situations
use guidelines and legal considerations
SOAP notes
S=subjective data
O=objective data
P=plan of action
-Each SOAP note represents one problem
-Ordered by priorities
Focus note - DARP
D=data (subjective & objective)
A=action (what you did)
R=client response
P=plan (continued plan?)
-Not as precise as SOAP note
-Order of documentation is determined by priorities
Legal Considerations
-Correction of errors (draw line and initial)
-Objective approach
-Continuous record
-Chart only for yourself
-Use black ink
-Write legibly
-Begin with date and time, end with your status (LMRCSN)
-If it isn't written you didn't do it!
Example of SOAP Nurses Note
Time 14:00
Nurses note: Pain
S: “I am having a migraine headache. I feel nauseated. Please give me some medicine. I rate my pain a 7. It feels like pressure over my left eye and causes my eye to tear.
O: Diaphoretic. Facial grimacing. Tearing left eye. Rubbing left forehead. Lights off in room shades on window pulled. BP 146/80 lying. P90 R20.
A: No relief from migrane. Pain persists
P: Administer pain medication. Teach distraction techniques. Kathy Mayer, R.N.
Example of SOAP Nurses Note
Time 1415
Nurses note: Pain
Ergotamine 2mg sublingual administered. Kathy Mayer, R.N.
Example of SOAP Nurses Note
Time 1500
Nurses note: Pain
S: “My migraine is a little better. I rate the pain a 4. My nausea is gone."
O: No facial grimacing. No diaphoresis. No rubbing left forehead.
A: Relief obtained from pain medication.
P: Teach use guided imagery to alleviate pain. Kathy Mayer, R.N.